Physician-Assisted Suicide: Finding a Path Forward in a Changing Legal Environment Imagine yourself with a disease that has recently be- come terminal. What kinds of treatments and options would be most important to you? Almost everyone would want to be sure their physicians had considered, if not tried, all potentially effective disease-directed therapy and best possible palliative treatments to max- imize their quantity and quality of life. Many patients would want to consider a timely transition to hospice care if no acceptable disease-directed therapies ex- isted, hoping to live as fully as possible for their remain- ing time, and then to die peacefully. On these points we are completely in sync with the American College of Physicians (ACP) position paper (1).
We also know that most patients would want to know that they could refuse burdensome treatments that may keep them alive but with a low quality of life. (In fact, most patients die having forgone some poten- tially life-sustaining treatment.) A substantial minority of terminally ill patients also would want some assurances about their ability to access or potentially activate a physician-assisted suicide if their suffering becomes un- acceptable (2). For many of these patients, the motiva- tion is to maintain control over the manner and timing of their own death (many have been making a series of very challenging decisions throughout their illness and see no reason not to stay in charge of the last phase). Others fear the potential of unacceptable physical suf- fering in the last phase of their illness, perhaps on the basis of experience. Still others might find that the pro- longed debility and dependence that might occur dur- ing the dying process are unacceptable (3).
Knowledge about what “last-resort” options are available (4), as well as which options one’s own doctor can support, would be reassuring to these patients. It would free their emotional energy for other psychoso- cial and spiritual matters potentially critical to this last phase of life, and most patients ultimately will not need a medically assisted death if they receive excellent end-
of-life care. However, even with the best possible palli- ative and hospice care, a small percentage of patients eventually will want direct assistance with dying now. Carefully exploring the why now for such requests and redoubling efforts to palliate suffering are the next steps, followed by an exploration of legally available options for responding (2).
The legal landscape for patients who want to end their life now is rapidly changing in North America and western Europe (5). Both physician-assisted suicide and voluntary active euthanasia have been legal in the Netherlands, Belgium, and Luxembourg for many years, and both recently were legalized in Canada. Physician-assisted suicide is now legal in 6 states and the District of Columbia (affecting one sixth of the U.S. population), whereas it remains either explicitly illegal or legally uncertain in the remaining states.
Most of the U.S. population favors legalization of physician-assisted death, although support decreases slightly when the word suicide is used in questionnaires (5). The medical profession’s views are decidedly mixed on the subject of legal access. Most U.S. physi- cians would want access for themselves, but a smaller percentage would be willing to provide assistance to their patients (6). Positions of professional organiza- tions also vary on this subject. For example, the ACP joins the American Medical Association in opposing the practice (1), whereas the American Academy of Hos- pice and Palliative Medicine has a neutral position, and the American Medical Student Association and the American Medical Women’s Association are in favor of legalization. How should individual physicians proceed when opinions are so deeply divided?
We clearly support the steps outlined in the ACP position statement with regard to “responding to pa- tient requests for assisted suicide” (1). However, if re- quests persist and the unacceptable suffering contin- ues, we believe all legally available last-resort options
This article was published at Annals.org on 19 September 2017.
Table 1. Last-Resort Options
Intervention Ethical Consensus Regarding Permissibility
Aggressive symptom management Widely accepted in North America and western Europe
Stopping or not starting life-sustaining therapy Widely accepted in North America and western Europe
Palliative sedation (potentially to unconsciousness) Consensus if death unintended; controversial otherwise
Probably permissible but never tested
Voluntarily stopping eating and drinking Some controversy, often depending on religious views
Probably permissible but never tested
Physician-assisted suicide Opinion about permissibility differs widely Legally permitted in 6 states and the District of Columbia; legality uncertain in most other states; legal in Canada
Voluntary active euthanasia Opinion about permissibility differs widely Illegal and likely to be prosecuted in the United States; legal in Canada
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should be explored (Table 1). Clinicians should deter- mine in advance which options they can and cannot personally support (4). They should extend themselves, if possible, to respond to their patients’ needs and re- quests without violating their fundamental personal val- ues, regardless of the status of the law. If a patient de- sires a legally permitted option that the physician cannot support and common ground cannot be found, the patient should be given the opportunity to change physicians in a timely way so that access is allowed.
Given the rapidly changing legal environment with regard to physician-assisted suicide and voluntary ac- tive euthanasia, we are concerned that concluding a guideline by stating “physicians should not do this” is a problematic public health response. Even if one per- sonally disagrees with the behavior, studying it might tell us much about the state of end-of-life care and how it can be improved. The Remmelink studies from the Netherlands (5) and Oregon Health Department data (7) provide examples of collecting meaningful informa- tion in an attempt to understand and improve practice. The scale and diversity of a state like California and a country like Canada warrant similar studies. Table 2 gives examples of areas that should be examined as these large-scale implementation efforts are under way.
In addition, we worry that the ACP’s rigid opposi- tion will prevent physicians who will practice physician- assisted suicide from sharing ideas about better poli- cies and procedures. Given the diversity of opinions and the legality of the procedure for so many people, this response seems like a missed opportunity to edu- cate clinicians and learn about best practices.
We should continue to debate the ethical and moral implications of permitting or prohibiting poten-
tially life-ending medical practices. We need to support an environment that both redoubles our efforts to pro- vide palliative and hospice care to all seriously ill pa- tients and enhances our imperative to listen and re- spond to those who still feel they may need an escape from the last stages of this process. We currently have an opportunity to learn about this process on a larger scale with a more diverse population than ever before. Let’s make sure our processes and safeguards are as robust and responsive as possible, and let’s learn as much as we can so that these new laws help us serve our patients and families in the best way possible.
Timothy E. Quill, MD University of Rochester Medical Center Rochester, New York
Robert M. Arnold, MD University of Pittsburgh Pittsburgh, Pennsylvania
Stuart J. Youngner, MD Case Western Reserve University Cleveland, Ohio
Disclosures: Disclosures can be viewed at www.acponline.org /authors/icmje/ConflictOfInterestForms.do?msNum=M17-2160.
Requests for Single Reprints: Timothy E. Quill, MD, University of Rochester Medical Center, 601 Elmwood Avenue, Box 687, Rochester, NY 14642; e-mail, firstname.lastname@example.org .edu.
Current author addresses are available at Annals.org.
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References 1. Snyder Sulmasy L, Mueller PS; Ethics, Professionalism and Human Rights Committee of the American College of Physicians. Ethics and the legalization of physician-assisted suicide: an American College of Physicians position paper. Ann Intern Med. 2017;167:576-8. doi:10 .7326/M17-0938 2. Quill TE. Doctor, I want to die. Will you help me? JAMA. 1993;270: 870-3. [PMID: 8340988] 3. Pearlman RA, Hsu C, Starks H, Back AL, Gordon JR, Bharucha AJ, et al. Motivations for physician-assisted suicide. J Gen Intern Med. 2005;20:234-9. [PMID: 15836526] 4. Quill TE, Lo B, Brock DW. Palliative options of last resort: a com- parison of voluntarily stopping eating and drinking, terminal seda- tion, physician-assisted suicide, and voluntary active euthanasia. JAMA. 1997;278:2099-104. [PMID: 9403426] 5. Emanuel EJ, Onwuteaka-Philipsen BD, Urwin JW, Cohen J. Atti- tudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe. JAMA. 2016;316:79-90. [PMID: 27380345] doi:10.1001/jama.2016.8499 6. Meier DE, Emmons CA, Wallenstein S, Quill T, Morrison RS, Cassel CK. A national survey of physician-assisted suicide and euthanasia in the United States. N Engl J Med. 1998;338:1193-201. [PMID: 9554861] 7. Oregon Health Authority. Death with Dignity Act Annual Reports. 2017. Accessed at www.oregon.gov/oha/PH/PROVIDERPARTNER RESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT /Pages/ar-index.aspx on 18 August 2017.
Table 2. Representative Study Questions to Understand the Effect of Legalization of Physician-Assisted Suicide
Cases Numbers Diagnoses Second opinions Presence of palliative care and/or hospice
Requests Main reason Acceptance rates Refusal rates Hypothetical future vs. now
Second opinions Who provides Palliative care certification Acceptance vs. refusal rates
Practical aspects Change in primary treating physician Number of visits from initial request Documentation Actual methods
Long-term effect Family members Participating clinicians Participating consultants Hospice workers
EDITORIAL Physician-Assisted Suicide: A Path Forward in a Changing Legal Environment
598 Annals of Internal Medicine • Vol. 167 No. 8 • 17 October 2017 Annals.org
Current Author Addresses: Dr. Quill: University of Rochester Medical Center, 601 Elmwood Avenue, Box 687, Rochester, NY 14642. Dr. Arnold: 1232 North Highland Avenue, Pittsburgh, PA 15206. Dr. Youngner: Department of Bioethics, Case Western Re- serve University, 10900 Euclid Avenue, Cleveland, OH 44106.
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The Slippery Slope of Legalization of Physician-Assisted Suicide
The American College of Physicians (ACP) positionpaper on the legalization of physician-assisted sui- cide reaffirms the ACP’s opposition to this practice, even though it is now legal in several countries and U.S. jurisdictions (1). The ACP’s position deserves credit for its clarity and courage.
Among other achievements, the ACP paper identi- fies “euthanasia” and “medical assistance in dying” as euphemisms. These terms do what euphemisms are supposed to do: make a distasteful subject palatable, or at least discussable. The social process of change in ethical and moral standards makes bold use of such euphemisms. At one time, “mercy killing” and physician-assisted suicide were both illegal and un- thinkable. However, times are changing, and the changes have followed a recognizable pattern (2). First, the unthinkable becomes discussable although highly controversial. After a while, it is seen as acceptable un- der certain circumstances. As it becomes more familiar, it seems increasingly sensible and reasonable. Finally, it is established as a legal right. In this way, what was once unthinkable can eventually become policy, or even a duty (3).
Space limitations permit only a brief consideration here of arguments for and against medically assisted suicide. The argument in favor that is based on “non- abandonment” ignores a conscientious physician’s commitment to relieve suffering and to accompany sick and dying patients to the very end. We all should provide “medical assistance in dying” and not abandon our suffering patients. This argument also tends to stig- matize those who object to suicide as a solution to suffering.
The “slippery-slope” objection to medical suicide and euthanasia may be dismissed as alarmist, but it is not easily refuted. Euthanasia was legalized in the Neth- erlands in 2002, with multiple safeguards against abuse. However, in 2015, the Dutch government re- ported that hundreds of persons were put to death without their express consent or because of psychiatric illness, dementia, or just “old age” (4). In addition, the Groningen protocol has legalized infanticide in the Netherlands. In view of these developments, it is laud- able that Oregon, Canada, and other jurisdictions have built safeguards into their end-of-life legislation. How- ever, a slope still exists, and it may be fairly steep.
The argument based on intractable suffering ap- peals to a physician’s sense of empathy. However, if hard cases make bad law, they also may produce un- wise medical policies, and the argument surely greases the slippery slope. If intractable physical suffering is a justification for actively ending life, why should intracta- ble existential angst, a severe sense of personal alien- ation, or the helplessness and hopelessness of severe depression not be as well?
The principle of patient autonomy seems the weightiest of the arguments in favor of medical eutha- nasia or suicide, and with good reason. It alone of the 4 pillars of medical ethics can survive Western society’s transition toward a post-Christian antinomianism. Be- neficence would now be defined as whatever the pa- tient believes to be helpful. Nonmaleficence and justice would be whatever the patient says they are, absent external standards. Autonomy alone would stand unas- sailed and, by default, carry the day. Who is to say that what I want for myself is the wrong thing?
A person might say it is wrong if he or she recog- nizes an objective moral standard, namely that human life has intrinsic worth and dignity and that its value extends beyond the individual to the community. This might be true even if its owner doesn’t recognize it for a time or if others believe that one’s life is “not worth living.” Some hold that this moral standard (along with many others) can be known from nature or discovered by reason. Others reach it intuitively or find it in revela- tion, still others in all of the above. Of course, in a plu- ralistic society, not everyone believes in or will agree on objective moral standards, or which one prevails when they seem to conflict.
One may reply that the dignity and worth of human life are not absolute values. For example, it is recog- nized that some life-prolonging treatments are dispro- portionate or even futile. However, as the ACP position paper points out, neither is patient autonomy an abso- lute value. We do not always give patients whatever they ask for: A futile treatment? No. An illegal prescrip- tion? No. We therefore find ourselves weighing differ- ent considerations with regard to assisted suicide. Many will give considerable weight to the presumption that human life is intrinsically valuable, especially in view of what may happen if this value is held as less compelling than autonomy, or utility, or health care economics.
The weakest part of the ACP’s position against medical suicide is its objection on the basis that such provision lies outside the scope of medical practice. I disagree. If assisted suicide and euthanasia are right and good, physicians should willingly accede; if they are wrong, they should not be done by anybody.
With clarity and courage, the ACP has reaffirmed its opposition to physician-assisted suicide. Perhaps the vote was close; the tide of opinion may be turning, and the next iteration of the ACP’s position might be differ- ent. Autonomy and self-determination are ascendant, and there are warnings of intolerance toward those who object. Nonetheless, physicians opposed to the provision of euthanasia and medically assisted suicide should not be cowed by attempts to place them “out- side the mainstream.” Where these practices are legal, I believe that physicians should firmly decline to participate.
This article was published at Annals.org on 19 September 2017.
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© 2017 American College of Physicians 595
It is time to return to our duty at the bedside. Our compassion calls us there, as Dr. Edward Trudeau is credited to have said, “to cure sometimes, to relieve often, to comfort always,” but not to kill or to assist in or facilitate killing. With time, we will see whether our col- lective cultural conscience, including respect for the in- trinsic value of human life, can keep us from sliding down the slope. Otherwise, it will merely mitigate our speed as we descend.
William G. Kussmaul III, MD Media, Pennsylvania
Disclosures: The author has disclosed no conflicts of interest. Form can be viewed at www.acponline.org/authors/icmje /ConflictOfInterestForms.do?msNum=M17-2072.
Requests for Single Reprints: William G. Kussmaul III, MD, 5 Arrowhead Trail, Media, PA 19063; e-mail, w.kussmaul @verizon.net.
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References 1. Snyder Sulmasy L, Mueller PS; Ethics, Professionalism and Human Rights Committee of the American College of Physicians. Ethics and the legalization of physician-assisted suicide: an American College of Physicians position paper. Ann Intern Med. 2017;167:576-8. doi:10 .7326/M17-0938 2. Marsh L. The flaws of the Overton window theory: how an obscure libertarian idea became the go-to explanation for this year’s crazy politics. New Republic. 27 October 2016. Accessed at https: //newrepublic.com/article/138003/flaws-overton-window-theory on 21 August 2017. 3. Stahl RY, Emanuel EJ. Physicians, not conscripts— conscientious objection in health care. N Engl J Med. 2017;376:1380-5. [PMID: 28379789] doi:10.1056/NEJMsb1612472 4. Francis N. Netherlands—2015 euthanasia report card. Dying for Choice Web site. Accessed at www.dyingforchoice.com/resources /fact-files/netherlands-2015-euthanasia-report-card on 18 August 2017.
EDITORIAL The Slippery Slope of Legalization of Physician-Assisted Suicide
596 Annals of Internal Medicine • Vol. 167 No. 8 • 17 October 2017 Annals.org
Copyright © American College of Physicians 2017.